Susan J. Bramlette, LMFT 9.1.17
Wind River Office Park
11615 Angus Rd. Ste. 117A
Austin, TX 78759
Phone: (512)356-9238
Fax: (512)233-1021
Please visit us at or
Welcome! Thank you for choosing us to address your healthcare needs. Initiating therapy, you may have many questions. Please ask questionsfreely about policies, state and insurance laws, referrals, and your private healthcare information rights.
Feel free to discuss any questions regarding your care at any time directly in session, or by phone (during business hours M-F 10 a.m. – 8 p.m.).
A.Registration: Please check the box next to the service you are seeking:
_ Couple’s Therapy: Each partner fills out/signs one form, medical information sheet.
_ Minor Client/Parent: Parent or Guardian fills out form for youth with Insured’s Info.
_ Individual Therapy: Fill out and sign all parts of the form that apply to you.
Date: ______Office: 183/Duval/Angus Rd.______
Client Name: ______
Self / partner of ______/minor child of______
Date of Birth: ______Age:_____ Social Security Number:______
Address: ______City: ______Zip: ______
Others in Client’s Residence:______
Phone number(s) we may reach you at:
(______) ______- ______home/work/cell
(______) ______- ______home/work/cell
Email address:______
Marital Status (circle): Single / Married / Divorced / Widowed / Other:______
B.Insured or Responsible Party’s Name: ______
Insured’s SSN:______Insured’s Address is same as listed above, or:
Insured’s Address: ______City: ______Zip: ______
Insured’s Date of Birth: ______Age: ______Marital Status: ______
Payment by (circle one): Self-pay /Employee Assistance Plan (EAP) /MH Insurance
Insurance Co. Name:______Mental Health Phone No.:______
Insurance ID No.:______Group No.:______
Authorization #______Authorization Set up in Name of:______
Other Arrangements:______
Please note: We have confidential, secure voicemail. Clients choosing to communicate via email () or text (503.956.5144) do so at their own risk. Text and email portals should not be considered secure per HIPPA standards.
Medical concerns -- Please check all individual items that concern you:
___Nerves
___Shyness
___Drug abuse
___Anger
___Stress
___Headaches
___Emory
___Loneliness
___Education
___Temper
___Bowel problems
___Depression
___Suicidal thoughts
___Alcohol use
___Sleep
___Work tiredness
___Ambition
___Inferiority feelings
___Career choices
___Dreams thoughts
___Fear
___Friends
___Self-control
___Relaxation
___Legal matters
___Making decisions
___Concentration
___Health problems
___Appetite/weight
___Stomach problems
___Finances
Please check all relationship items that concern you:
___Closeness
___In-laws
___Communication
___Friendships
___Infidelity
___Recreation
___Partner’s cleanliness
___Trusting each other
___Solving problems together
___Sexual desire
___Parenting
___Relatives
___Use of time
___Verbal fighting
___Housing
___Showing appreciation
___Having fun together
___Affection
___Common goals
___Finances
___Jealousy
___Physical fighting ___Agreeing on chores
___Common interests
___Holding other back
Any further relationship concerns not listed above? ______
______
Mood Scale – Please indicate your general mood level for the last month by drawing a circle around the numbers.
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Suicide ideas Depression Average Good Spirits Joyful
Now, mark an “L” over one of the numbers above to describe the LOW point of your mood during the last year.
Anxiety Scale – Please place an “X” over one of the numbers on the 1 to 10 scale below to indicate your general level of anxiety or nervousness over the last month.
The higher the number, the higher the level of anxiety, nervousness, and tension you are reporting.
1 2 3 4 5 6 7 8 9 10
Peaceful Panicky
Previous therapy experience:
Have you ever been in therapy before?____Yes____NoIf yes, please describe below:
______
Name of therapist ______Dates ______
What was helpful and not helpful about this treatment? ______
How did you hear about us? (Check one) (Optional)
__ Friend or family member______ Other:______
__ Internet Search of:______
__ Professional referral /Yellow Pages/ Brochure /Insurance Panel
Employment
Your Job Title:______Employer:______
Partner’s Job Title:______Employer:______
C: Professional Disclosure Statement and Policies
We honor your time and Thank You for your patience in waiting.
Appointments are generally 50-60 minutes in length, yet can run later as need requires. Sessions beginning at ten minutes after will complete on the Hour.
Sessions beginning on the Hour will Complete at ten minutes ‘til
to allow for copay, appointment-setting and smooth transition.
1. Education: Susan Bramlette earned a masters degree in Marriage and Family Therapy at the University of Oregon and Northwest Christian College, Eugene, Oregon, Y2000.
She is licensed by the States of Texas and Oregonand specializes in couples, adolescent, adult, and family therapy. She is a clinical member of the American Association of Marriage and Family Therapists (AAMFT.org) and a member of Psi Chi, the American Psychological Association Honor Society.
2. Communication: An Open Therapeutic Approach
a. Your counselor practices Systemic, Bowenian, Intergenerational, and Cognitive-Behavioral Therapy, while other treatment approaches, such as Crisis Management protocol, are also resourced when indicated. Links on Susan’s website provide more information on these modalities.See
b.Susan counsels/supports children in family crisis; Shedoes not participate in custody cases.If you anticipate involvement in a court custody dispute, please advise for a proper referral to a custody evaluation provider.
b. Couples are asked to commit to ten sessions in order to support long-term, effective outcomes. Between-session assignments help speed progress toward reaching your goals. Recommended resource books are listed on the website.
c. Treatment practices, philosophy, business matters, or limitations and risks of therapy may be discussed at any time.Your questions are always welcome.
3. Affiliation: I abide by the Code of Ethics of: the Texas State Board of Examiners of Marriage and Family Therapists/ Mail Code 1982, P.O. Box 149347, Austin, TX 78714 and the Oregon Board of Licensed Professional Counselors and Therapists/ 3218 Pringle Road SE Suite 250Salem, OR 97302-6312(503) 378-5499, as well as the Code of Ethics of the American Association of Marriage and Family Therapy (AAMFT).
4. Confidentiality, Notice of Privacy Practices, and Client Rights
Your verbal communication and clinical records are held in strictest confidence. Some exceptions apply by law when:
a)Billing Staff: information (date of service, etc.) is shared with our staff to expedite your self-pay and insurance billings,
b)Medical Billing: information is shared with your insurance carrier to process your claim,
c)Abuse: information provided by you and/or your child/elder discloses the possibility that verbal, physical or sexual abuse may be occurring, which by Texas state law I am required to report to the Dept. of Children and Family Services.
d)Records Request: you sign a release of information requesting that your health care information be shared with a physician, disability insurer, specific other (i.e., your designated emergency contact, below), or,
e)Duty to Warn: you provide information that informs me you may be in danger of harming yourself or another person,
f)Best Practices: information required for case consultation with professional colleague, or,
g) Subpoena: when disclosure is required by law.
h)“No Secrets” Policy: Susan asks those in couple’s therapy not to reveal facts they do not wish their partner to know. Secret-keeping is not a contractual agreement in couple’s therapy. Partners who prefer to retain secrets from a partner should ask for a referral for individual therapy before entering a season of marital/couple’s therapy in order to ensure this privilege, which is not guaranteed in my couple’s work.
Please sign:
I/we have read and understand this Notice of Privacy Practices/Client Rights.
______
5. Records Access
a)Records are retained for seven years.
b)Records requests must be made in writing with a specific designation of person, address, private healthcare information requested clearly designated. 72-Hour minimum response.A current release of information must be signed and on file.
c)The fee for preparation, copying, mailing of records is listed below.
d)Custodial parents, non-custodial parents, or legal guardians of non-emancipated minor clients have the right to access the client’s record upon written request.
e)Request for access to stored records in transitional/post practice situations may be made by phoning Dr. James Boyer, P.C., LMFT, at 503.224.3522.
6.Emergency Protocol: In an emergency situation where the client or his/her guardian deems that immediate attention is necessary, contact the emergency services in the community (911) immediately. Susan Bramlette will follow emergency services with counseling support to the client and family in a timely manner.
*Please advise as soon as possible at 512.356.9238 after obtaining emergency care.
a. Emergency Contact (Required):______
Relationship:______
Telephone:______Email:______
b. ______(initial) Permission is given to contact the above individual to discuss treatment needs deemed emergency in nature. Other preferences:____________
7. Current Prescriptions/Coordination of Treatment with Prescribing Physician/
Current Prescription Medicines in Use: ______
______
Previous Prescription Medicines: ______
______
Prescribing Physician’s Name: ______
Current clinic/City: ______Telephone or fax: ______
If you wish to authorize communication with your primary care physician and/or other treating professional, please indicate below and fill out the Authorization to Release to Disclose Medical Records form. Your consent is valid for one year or until such time as consent is revoked in writing.
____Please notify my physician. ____I decline notification of my physician at this time.
8. Financial/Insurance Information
Insurance providers with whom we have current contract agreements are:
EAP Consultants/ESPYR Blue Cross/Blue Shield
Empathia EAP/Life Matters Definity CorpHealth
Cigna Behavioral Health Cigna EAP PHCS/MultiPlan
NDBH (New Directions) Sterling EAPFEI EAP
Humana/LifeSyncEAP Preferred
Please ask concerning other insurances; single-case agreements may be available.
Insurance clients: Please call the number for Behavioral/Mental Health or Employee Assistance (EAP) Services listed on your insurance card for instructions and provide our billing staff with the following information:
- Client and Insured’s identification/Group/Authorization number information.
- Insurance Company, type (EAP or Mental Health benefit), Date of Authorization Start, Deductible/Deductible satisfied? Please bring your card to the 1st session.
- Information given by your insurance company about number of sessionsauthorized, authorization number,co-payment/co-insurance requirements, as well as the specific billing address and telephone number.
If you have not satisfied your deductible, insurance rate fee is due at session until met.
My deductible is $______. It is satisfied/notsatisfied (circle one).
My copay is: ______. Payment today is:______.
*Please advise of any changes to your insurance plan or benefits. Thank you!
9. Fee Schedule for Services Sliding scale available per prior agreement
Intake Appointment (60- 70 minutes): $140
Individual Appointment (50-60 minutes): $120
Couples, Family Therapy (50-60 min /60-70 min):$140
Group Therapy (90 minutes)$30
Calls/Letters/Forms/Records Requested by Client in writing$60
Missed Appointment Fee (billed same day via Paypal)$30
Prepaid Block/ Ten Sessions couples’ or individual$950.
Gottman Assessment and Four Sessions $700.
a)______(initial) As a courtesy we will bill insurance or third-party payor for you, then advise of denied claims, co-insurance required, etc. Please resolve these a.s.a.p. Accounts receivable over $100 cannot be carried or expanded.
b) Fees can be paid by cash, check, credit or Debit card (via Square), Paypal response to email invoice, Paypal at or by telephone.
c) Copay or Private-Pay session fee is due at the start of session. Thank you!
d) You may choose to put a card on file to cover copays, late cancellations.
e) ______(initial) Client Agreement: If my insurance company denies payment of my claim for any reason, I accept responsibility for balance due at the time of EOB statement or to make arrangements for payments. After 60 days an unpaid balance on my account will be charged 5% invoicing fee a month on balance due.
f)______(initial) I understand my anticipated fees for therapy and/or I will contact my provider with any questions about fees.
g) ______(initial)Late Cancellation Policy - If I need to cancel or reschedule an appointment, I will give 24 hours advance notice at: 512.356.9238 or pay a 30 missed appointment fee. Please note: This is a very modest administration fee; your understanding of the cost of providing multiple services (scheduling, billing, record-keeping) and clinical preparation time is sincerely appreciated.
A copy of this Professional Disclosure Statement is available 24/7 at
10. Consent to Treatment: I understand the policies in this statement. I give my permission to begin treatment with Susan Bramlette, LMFT.
Signature______Date______
Client
Signature______Date______
(Signature of parent(s) or guardian for a minor child)
______I acknowledge that I am acting in compliance with my custody agreement and that parent, ______, has/does not have, rights to ______’s medical record.
Susan J. Bramlette, LMFT
Wind River Office Park
11615 Angus Rd. Ste. 117A
Austin, TX 78759
Phone: (512)356-9238
Fax: (512)233-1021
Please visit us at or
Couples and Families: Please review and sign below. Thank you!
LIMITATIONS OF CONFIDENTIALITY WHEN WORKING WITH COUPLES OR FAMILIES (THE “NO SECRETS” POLICY):
In my Professional Disclosure Statement you read about the legal issue of confidentiality that I will not release any information about our sessions to a third party without your written permission.The exceptions to this would include instances where I legally have to report concerns about your safety or the safety of others or if I am subpoenaed to disclose information.
In our work together, I may choose to see you or a part of your family separately.This will be considered part of our course of therapy and confidentiality as stated above and in the Professional Disclosure Statement still applies.However, there may be instances in which I need to share information learned in an individual session with your partner or other family member.I will use my best clinical judgment as to whether, when and to what extend I will make those disclosures to others involved in the therapy process.I will also give the individual the option and opportunity to share that information with the other(s) or larger part of those involved in the therapy process.If you feel it necessary to talk about matters that you absolutely do not want the other(s) to know, you might want to consult with an individual therapist who can treat you individually.
This “No Secrets” policy is intended to allow me to continue to treat the couple or family by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of those involved in the therapy process.For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple or family.If I am not free to exercise my clinical judgment regarding the need to bring this information to the couple or family, I might be placed in a situation where I will have to terminate treatment of the couple or family.This policy is intended to prevent the need for such a termination.
By signing below, you as members of the couple/family or other unit receiving services/therapy acknowledge that each of you has read and understand this policy, that you have had an opportunity to discuss its contents with me as your therapist and that you undertake couple/family therapy in agreement with this policy.
Date: ______Signature:______
Date: ______Signature:______
Susan J. Bramlette, LMFT
Wind River Office Park
11615 Angus Rd. Ste. 117A
Austin, TX 78759
Phone: (512)356-9238
Fax: (512)233-1021
Please visit us at or
Please complete and sign this document if you would like me to consult with any other professional who is, or has been, involved with your treatment.
Consent to Release and/or Receive Confidential Information
I, ______, hereby authorize Susan Bramlette LMFT for the purpose of coordination of treatment
_____to have phone contact _____release to _____release from
______
Name of person/facility/agency
______
Address Phone number Fax number
My address is:______
City:______State:______Zip code ______
Phone number:______Date of birth: ______
Expiration date: ______
I understand that the above consent is subject to revocation by me at any time except to the extent that action has been taken in reliance on the consent prior to revocation.In any event, if no expiration date is specified above, this consent will automatically expire one year from the date noted below.
Client signature Date